Provider Demographics
NPI:1003239807
Name:KENNEDY, JOHN JR (MA)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:
Last Name:KENNEDY
Suffix:JR
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7291 TALBERT AVE
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92648-1232
Mailing Address - Country:US
Mailing Address - Phone:714-842-6600
Mailing Address - Fax:714-842-6607
Practice Address - Street 1:3737 MARTIN LUTHER KING JR BLVD
Practice Address - Street 2:SUITE 550
Practice Address - City:LYNWOOD
Practice Address - State:CA
Practice Address - Zip Code:90262-3513
Practice Address - Country:US
Practice Address - Phone:310-609-3890
Practice Address - Fax:310-609-0301
Is Sole Proprietor?:No
Enumeration Date:2014-01-29
Last Update Date:2016-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA01245407OtherMEDICAL